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Neoplasia in colonic mucosa
HUMAN PATHOLOGY
Volume 14, No. 'I (January '1983)
educational vahte o f the procedure. By sttbtnitting these imtnediate constthation reports we may help the antopsy regain its fortner position o f etninence as a nmjor learning experience in any medical center. CYRIL ABRAHAMS, MD Department of Pathology Michael Reese Hospital and Medical Center Ctficago, Illinois 1. AbrahamsC: The "Scrimp"technique: a method for the rapid diagnosis of surgical pathologyspecimens, ttistopathology2:255, 1978
T H E INADEQUACY OF AUTOPSY EXAMINATIONS To the Editor:--From the experience o f having personall)" performed about 12,000 atttopsies (including about 2,000 tnedicolegal ones), I completely agree with Dr. K. H. W o o d r u f P concerning the irrelevance o f a large percentage o f autopsy examinations and share in her conchtsion that this is the reason that the value o f atttopsies has been questioned by many clinicians. I received tny pathology training first as an extern, then as First Assistant to Professor Jacob Erdheim at Vienna Municipal Hospital from 1927 to 1932, but I also completed a five-year residency in internal tncdiciue at the same hospital. In the Pathology Institute o f Professor Erdheitn, 2,400 atttopsies were perfortned )'earl)' (an average o f more than 6.5 per day). Clinical correlation was essential in each one: the autopsies were attended by clinicians, and many were personally performed by Pl:ofessor Erdheim; those that were not, were checked by him. In contrast, many autopsies currently are perfortned by the youngest, least knowledgeahle resident, who got his training, or lack o f it, from his next youngest colleague and whose lack o f pathology knowledge is matched only by Iris inexperience in clinical medicine. He generally does not have the knowledge, nor does he take the time, to review in depth the often vohttnitmus charts prior to the atttopsy for the essential clinical correlation. T h e Diener--an essential helper, always available in Vienna--far exceeds his competence by taking out organs prior to the autopsy withont proper supervision, and may thereby cotnpletely destroy essential landmarks and anatomic relationships, or he may omit essential organs (snch as the skeleton). To today's pathologist, a comprehensive atttopsy protocol is extretnely titne-consuming and financially ttnrewarding. The autopsy is not considered a "cost-effective" procedure; indeed, it is not cost-effective if it is inadequate. However, if it is adequate, it's effectiveness tnay be immeasurable, even if tnedical myopia causes it to be seen otherwise. A combination o f inexperience, time constraints, and
lack o f tnotivation is deadly to the competent perfortnance o f autopsy exatninalious. Unless this trend is reversed, the autopsy, although surviving in natne, will he an entlangered, perhaps vanishing, species, and its reptttation, instead of being distinguishcd, will rightfldly be extinguished. LEO LOWBEER, MD Chief Consuhant Pathologist ttillcrest Medical Center and Oklahoma State Board of Medicolegal Investigations Tulsa, Oklahoma 1. Woodrnff K[I: The relevance of autopsy examination (letter). 11um Pathol 13:605, 1982 NEOPLASIA IN C O L O N I C MUCOSA To the Editor:~I feel compelled to reply to the article entitled "Microscopic Intraepithelial Neoplasia in Large Bowel Mucosa," by Dr. Shamsuddiu, 1 which appeared in the May 1982 issue. T h e author purports to show early neoplasia in grossly normal colonic mucosa from two patients who had no signs o f inflamtnatory bowel disease. T h e report is accompanied by two illustrations, neither o f which, in my opinion, shows any evidence of iotraepithelial neoplasia. Figure 1 shows partially denuded mucosa, obtait/ed at autopsy, with sotne dilated crypts attd crypt abscesses. The crypts that are apparently designated as "atypical" contain many fully differentiated goblet cells--a finding that should arouse great hesitation before preinvasive cancer is diagnosed. Fignre 2 shows tangentially cut colonic crypts with epithelittm that differentiates in a normal fashion to the surface, althougtl there may be a slightly elongated zone o f replication in their lower halves. A similar article by the same attthor appeared in another journal in 19812 and was followed by a letter o f severe criticism signed by all the members of the Inflammatory Bowel Disease-D)'splasia Morphology Study G r o u p ? T h e current article by Dr. Shamsuddin takes no heed o f the recommendations o f the I B D - D M S G . T h e therapeutic implications o f the article are dangerous and represent a threat to both the health o f patients and the credibility o f diagnostic pathologists.
ROBERTR. PASCAL,MD Director, Anatomic Pathology St. Luke's-Roosevelt Hospital Center New York, New York l. Shamsuddin AM: Microscopic intraepithelial neoplasia in large bowel mucosa. Hum Pathol 13:510, 1982 2. Shamsuddin AM: Preneoplastic and neoplastic changes in colonic mucosa in Crohn's disease. Arch Pathol 105:283, 1982 3. Haggitt RC, Appelman HD, Correa I', et al: Carcinoma or dysplasia in Crohn's disease. Arch Pathol 106:308, 1982
BOOK REVIEWS Prostate Cancer. (International Perspectives in Urology, volume 3.) Edited by GUNTtiER H. JacoBI and RUDOLV HOtIENVELLNEg. Baltimore, Williams & Wilkins Co, 1982. 490 pages, illustrated. $58.00. Clinical management o f cancer o f the prostate is not standardized. Many urologists still treat metastatic disease with transu'rethral resection and orchiectomy or estrogen therapy. Advocates of other accepted modes o f therapy, including radical prostatectomy, external beam radiotherapy, and interstitial radiation treatment, are debating the
virtues and drawbacks o f their respective approaches. T h e nltimate usage of hormonal manipulation with new antiandrogen and antiprolactin drugs remains unsettled but still holds promise. Prostate Cancer is a multiauthored book that represents a serious effort to address current controversies in the management and pathologic evaluation o f this disease. In 25 chapters, 22 authors from seven European countries and Japan provide a broad perspective of prostate cancer investigative fields, both clinical and experimental. T h e editors, two talented German urologists, have encouraged the ex-
Volume 14, No. 'I (January '1983)
educational vahte o f the procedure. By sttbtnitting these imtnediate constthation reports we may help the antopsy regain its fortner position o f etninence as a nmjor learning experience in any medical center. CYRIL ABRAHAMS, MD Department of Pathology Michael Reese Hospital and Medical Center Ctficago, Illinois 1. AbrahamsC: The "Scrimp"technique: a method for the rapid diagnosis of surgical pathologyspecimens, ttistopathology2:255, 1978
T H E INADEQUACY OF AUTOPSY EXAMINATIONS To the Editor:--From the experience o f having personall)" performed about 12,000 atttopsies (including about 2,000 tnedicolegal ones), I completely agree with Dr. K. H. W o o d r u f P concerning the irrelevance o f a large percentage o f autopsy examinations and share in her conchtsion that this is the reason that the value o f atttopsies has been questioned by many clinicians. I received tny pathology training first as an extern, then as First Assistant to Professor Jacob Erdheim at Vienna Municipal Hospital from 1927 to 1932, but I also completed a five-year residency in internal tncdiciue at the same hospital. In the Pathology Institute o f Professor Erdheitn, 2,400 atttopsies were perfortned )'earl)' (an average o f more than 6.5 per day). Clinical correlation was essential in each one: the autopsies were attended by clinicians, and many were personally performed by Pl:ofessor Erdheim; those that were not, were checked by him. In contrast, many autopsies currently are perfortned by the youngest, least knowledgeahle resident, who got his training, or lack o f it, from his next youngest colleague and whose lack o f pathology knowledge is matched only by Iris inexperience in clinical medicine. He generally does not have the knowledge, nor does he take the time, to review in depth the often vohttnitmus charts prior to the atttopsy for the essential clinical correlation. T h e Diener--an essential helper, always available in Vienna--far exceeds his competence by taking out organs prior to the autopsy withont proper supervision, and may thereby cotnpletely destroy essential landmarks and anatomic relationships, or he may omit essential organs (snch as the skeleton). To today's pathologist, a comprehensive atttopsy protocol is extretnely titne-consuming and financially ttnrewarding. The autopsy is not considered a "cost-effective" procedure; indeed, it is not cost-effective if it is inadequate. However, if it is adequate, it's effectiveness tnay be immeasurable, even if tnedical myopia causes it to be seen otherwise. A combination o f inexperience, time constraints, and
lack o f tnotivation is deadly to the competent perfortnance o f autopsy exatninalious. Unless this trend is reversed, the autopsy, although surviving in natne, will he an entlangered, perhaps vanishing, species, and its reptttation, instead of being distinguishcd, will rightfldly be extinguished. LEO LOWBEER, MD Chief Consuhant Pathologist ttillcrest Medical Center and Oklahoma State Board of Medicolegal Investigations Tulsa, Oklahoma 1. Woodrnff K[I: The relevance of autopsy examination (letter). 11um Pathol 13:605, 1982 NEOPLASIA IN C O L O N I C MUCOSA To the Editor:~I feel compelled to reply to the article entitled "Microscopic Intraepithelial Neoplasia in Large Bowel Mucosa," by Dr. Shamsuddiu, 1 which appeared in the May 1982 issue. T h e author purports to show early neoplasia in grossly normal colonic mucosa from two patients who had no signs o f inflamtnatory bowel disease. T h e report is accompanied by two illustrations, neither o f which, in my opinion, shows any evidence of iotraepithelial neoplasia. Figure 1 shows partially denuded mucosa, obtait/ed at autopsy, with sotne dilated crypts attd crypt abscesses. The crypts that are apparently designated as "atypical" contain many fully differentiated goblet cells--a finding that should arouse great hesitation before preinvasive cancer is diagnosed. Fignre 2 shows tangentially cut colonic crypts with epithelittm that differentiates in a normal fashion to the surface, althougtl there may be a slightly elongated zone o f replication in their lower halves. A similar article by the same attthor appeared in another journal in 19812 and was followed by a letter o f severe criticism signed by all the members of the Inflammatory Bowel Disease-D)'splasia Morphology Study G r o u p ? T h e current article by Dr. Shamsuddin takes no heed o f the recommendations o f the I B D - D M S G . T h e therapeutic implications o f the article are dangerous and represent a threat to both the health o f patients and the credibility o f diagnostic pathologists.
ROBERTR. PASCAL,MD Director, Anatomic Pathology St. Luke's-Roosevelt Hospital Center New York, New York l. Shamsuddin AM: Microscopic intraepithelial neoplasia in large bowel mucosa. Hum Pathol 13:510, 1982 2. Shamsuddin AM: Preneoplastic and neoplastic changes in colonic mucosa in Crohn's disease. Arch Pathol 105:283, 1982 3. Haggitt RC, Appelman HD, Correa I', et al: Carcinoma or dysplasia in Crohn's disease. Arch Pathol 106:308, 1982
BOOK REVIEWS Prostate Cancer. (International Perspectives in Urology, volume 3.) Edited by GUNTtiER H. JacoBI and RUDOLV HOtIENVELLNEg. Baltimore, Williams & Wilkins Co, 1982. 490 pages, illustrated. $58.00. Clinical management o f cancer o f the prostate is not standardized. Many urologists still treat metastatic disease with transu'rethral resection and orchiectomy or estrogen therapy. Advocates of other accepted modes o f therapy, including radical prostatectomy, external beam radiotherapy, and interstitial radiation treatment, are debating the
virtues and drawbacks o f their respective approaches. T h e nltimate usage of hormonal manipulation with new antiandrogen and antiprolactin drugs remains unsettled but still holds promise. Prostate Cancer is a multiauthored book that represents a serious effort to address current controversies in the management and pathologic evaluation o f this disease. In 25 chapters, 22 authors from seven European countries and Japan provide a broad perspective of prostate cancer investigative fields, both clinical and experimental. T h e editors, two talented German urologists, have encouraged the ex-